Someone asked me recently if I was a socialist. I guess it depends on your definition. I believe in personal responsibility, freedom of expression, family, and duty. I do not want to be told what to think; I believe it’s OK to be aspirational and within reason to be wealthy. Nothing wrong with free enterprise so long as it is properly regulated. Equality of opportunity, not equality of outcome. But I do not believe in private medicine because everyone’s health is equally important. And treating patients as customers is fatal, as opioid prescription addiction is destroying the US. Health care in the US is as bad as it gets, with many with too little care and most poisoned by too much health care. Money distorts every single contact. Nationalisation of health care is a no-brainer at every parameter you consider.
We don’t have private health care in the NHS, do we? We do. GPs are private subcontractors to the NHS operating for profit partnership. This fact is lost on most people, who wrongly assume that we are salaried like our hospital colleagues. But this is the legacy of Bevan’s compromise to the medical trade union. Health care was not completely nationalised in 1948. But the profession has changed profoundly.
General practice functions well and to a high quality. However, there has always been unacceptable variation in quality of care between local general practices. Two neighbouring practices can have huge differences in prescribing and referral rates yet will be servicing the same populations. All too often access is poor, communication terrible, there are dirty, tumbledown practices, wide variations of practice staff pay, widespread unchecked tyrannical behaviour, and virtually no oversight. We can’t recruit new doctors, for there is no career structure and no possibility of progression. The current crisis is casting up new opaque business structures. Do you fancy working for a large for-profit medical conglomerate? — hardly a rallying recruitment call. General practice is the largest specialism but has the weakest voice for we are splintered into tiny warring units. Today no one wants in and everyone wants out — record numbers of practices are closing.1
And there is the unspoken truth: the government won’t invest in primary care because it fears any new money will simply be taken as profit by the partners with no improvement in patient care. For we are business people with deep financial conflicts of interest. The BMA is conflicted and blind too. It genuinely wants to improve care but its primary function is to maintain the income and status of the profession, which undermines the BMA’s position as an honest broker in all negotiations. The current situation isn’t working; the small business partnership model is Cheyne Stoking its last. What to do? Drift for another disastrous decade. Do this and there will be nothing left. There is only one logical solution.
Time to nationalise general practice. Have a new vision, a new fully integrated primary care with multidisciplinary teams, build new health centres, systematically merge practices, manage clinicians, manage their prescribing, and standardise care. Time for a salaried service that mirrors that of our hospital colleagues. Nationalisation will raise our status, give us a voice, allow more research, and bring primary and secondary care together. It will certainly cost more but it needs to cost more. It will be no nirvana. It will see a loss of control and reduced earnings for some. It might be frustrating, bureaucratic, and inefficient too. But everyone has more to gain than lose. Nationalisation isn’t about socialism, it’s about pragmatism.
- © British Journal of General Practice 2019
REFERENCE
- 1.↵
(May 31, 2019) Pulse, The full story on how practices are closing in record numbers. .
